Nokea
During a nonstress test for a pregnant client, a nurse uses an acoustic vibration device. The client inquires about its purpose. Which response should the nurse provide?
- A. It is used to stimulate uterine contractions.
- B. It will decrease the incidence of uterine contractions.
- C. It lulls the fetus to sleep.
- D. It awakens a sleeping fetus.
Correct Answer: D
Rationale: The correct answer is D because the acoustic vibration device is used during a nonstress test to wake up a sleeping fetus, ensuring that the baby is active and responsive during the test. This helps to assess the baby's well-being and monitor its heart rate patterns. Choice A is incorrect as the device does not stimulate uterine contractions. Choice B is incorrect as it does not decrease the incidence of contractions. Choice C is incorrect as the device does not lull the fetus to sleep, but rather ensures the fetus is awake and moving during the test.
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A client is postpartum and has idiopathic thrombocytopenic purpura (ITP). Which of the following findings should the nurse expect?
- A. Decreased platelet count
- B. Increased erythrocyte sedimentation rate (ESR)
- C. Decreased megakaryocytes
- D. Increased WBC
Correct Answer: A
Rationale: Step 1: In idiopathic thrombocytopenic purpura (ITP), there is a decreased platelet count due to immune-mediated destruction of platelets.
Step 2: This leads to an increased risk of bleeding and bruising in the postpartum client.
Step 3: Other choices are incorrect because in ITP, there is no increase in ESR or WBC. Also, megakaryocytes may be normal or increased due to compensatory production.
When providing care for a client in preterm labor at 32 weeks of gestation, which medication should the nurse anticipate the provider will prescribe to hasten fetal lung maturity?
- A. Calcium gluconate
- B. Indomethacin
- C. Nifedipine
- D. Betamethasone
Correct Answer: D
Rationale: Step 1: Betamethasone is a corticosteroid that promotes fetal lung maturity by stimulating the production of surfactant, essential for lung function.
Step 2: At 32 weeks, the fetus may benefit from accelerated lung development to reduce respiratory distress.
Step 3: Calcium gluconate is used for hypocalcemia, not for fetal lung maturity.
Step 4: Indomethacin is a nonsteroidal anti-inflammatory drug used to delay preterm labor, not for lung maturity.
Step 5: Nifedipine is a calcium channel blocker to prevent preterm labor, not for fetal lung maturity.
A client is reinforcing discharge teaching with a client who has premature rupture of membranes at 26 weeks of gestation. Which of the following instructions should the client include?
- A. Use a condom with sexual intercourse
- B. Avoid bubble bath solution when taking a tub bath
- C. Wipe from front to back when performing perineal hygiene
- D. Keep a daily record of fetal kick counts
Correct Answer: D
Rationale: The correct answer is D: Keep a daily record of fetal kick counts. This is important for monitoring fetal well-being, especially in cases of premature rupture of membranes. By counting fetal kicks daily, the client can assess fetal movements and report any changes promptly to healthcare providers. This helps in early detection of fetal distress or problems.
A: Using a condom with sexual intercourse is not relevant to the situation of premature rupture of membranes.
B: Avoiding bubble bath solution is important for preventing vaginal infections but not directly related to monitoring fetal well-being.
C: Wiping from front to back during perineal hygiene is a general hygiene practice and not specific to the situation of premature rupture of membranes.
A client who received carboprost for postpartum hemorrhage is being assessed by a nurse. Which of the following findings is an adverse effect of this medication?
- A. Hypertension
- B. Hypothermia
- C. Constipation
- D. Muscle weakness
Correct Answer: A
Rationale: The correct answer is A: Hypertension. Carboprost is a prostaglandin used to treat postpartum hemorrhage that can cause hypertension as an adverse effect due to its vasoconstrictive properties. This can lead to increased blood pressure, which should be monitored closely. Hypothermia (choice B) is not a common adverse effect of carboprost. Constipation (choice C) and muscle weakness (choice D) are also not typically associated with carboprost use. Monitoring blood pressure and signs of hypertension is crucial due to the potential adverse effects of carboprost.
A healthcare professional is providing information to a group of clients who are pregnant about measures to relieve backache during pregnancy. Which of the following measures should the healthcare professional include? (Select all that apply)
- A. Avoid any lifting
- B. Perform Kegel exercises twice a day
- C. Perform the pelvic rock exercise every day
- D. Avoid standing for prolonged periods
Correct Answer: C
Rationale: The correct answer is C: Perform the pelvic rock exercise every day. This exercise helps strengthen the core muscles, which can alleviate backache during pregnancy. It also promotes flexibility in the lower back and pelvis.
Avoiding any lifting (A) is not a practical measure as some lifting may be necessary in daily activities. Performing Kegel exercises (B) strengthens pelvic floor muscles but does not directly address backache. Avoiding standing for prolonged periods (D) can help reduce backache but is not as effective as specific exercises targeting the back muscles like the pelvic rock exercise.